Elderly predialysis care pathways and early morbidity-mortality upon start of dialysis.

BACKGROUND AND HYPOTHESIS: The ageing of the population with advanced chronic kidney disease (CKD) increases the complexity of care pathways. Our aim was to identify subgroups of older people according to predialysis care pathways and describe their association with early morbidity-mortality after transition to dialysis. METHODS: This study included 22,128 incident dialysis patients aged ≥ 75 years during 2009-2017 from the French nationwide registry linked to the National Health Data System. Predialysis care pathways were identified by ascending hierarchical classification based on preselected healthcare use indicators in the previous year. Their association with a composite outcome of death or hospitalization ≥ 50% of the time off dialysis within the first year of dialysis was studied by multivariable logistic regression accounting for demographics, comorbidities, functional status, conditions of dialysis initiation, socioeconomic deprivation index, and home-to-dialysis center travel time. RESULTS: Five care pathway profiles were identified, characterized by limited healthcare use (cluster 1, 28%), non-nephrology ambulatory care (cluster 2, 17%), nephrology ambulatory care (cluster 3, 37%), and a high level of non-nephrology or nephrology hospitalizations (clusters 4 and 5, both 9%). Profile subgroups did not differ according to patient age and comorbidities, but clusters 1, 2 and 4 displayed higher levels of social deprivation. Compared to cluster 3, the odds ratios of primary composite outcome were significantly increased for clusters 1, 4, and 5 (OR (95% CI) of 1.16 (1.08-1.25), 1.17 (1.05-1.32), and 1.12 (1.01-1.25) respectively). Moreover, prolonged hospitalizations were also more common in all groups, compared to cluster 3. CONCLUSION: Despite similar comorbidity profile, older people with advanced CKD experience very heterogeneous predialysis care pathways, some of which associated with higher burden of hospitalization after the transition to dialysis.

A New Procedure for Guidewire Exchange of Tunneled Hemodialysis Catheters in Chronic Hemodialysis Patients: A Pilot Study.

INTRODUCTION: Different techniques of guidewire exchange of tunneled catheters for hemodialysis (HD) have been reported. This study was carried out to assess the feasibility of a new procedure in chronic HD patients who needed catheter exchange because of mechanical dysfunction. METHODS: The guidewire exchange method was based on the creation of a new exit site and a new subcutaneous tunnel while using the same venous insertion site. This was a retrospective study of exchanged tunneled catheters because of mechanical complications in patients on chronic HD between June 1, 2015, and December 31, 2019. The feasibility of the procedure was defined by successful exchange and catheter patency at 6 months. Catheter survival and immediate complications were reported. RESULTS: A total of 49 procedures were performed in 34 HD patients. There was no catheter insertion failure. At 6 months, 6 catheters have lost their patency because of a mechanical complication. Thus, the success rate of the procedure was 43/49 (87.8%). Catheter survival censored on death, transplantation, or vascular access creation was 97.8% at 90 days, 86.2% at 180 days, and 74.5% at 1 year. The median catheter survival was 10.2 months. Among the 49 procedures, there were 9 hematomas at the insertion site that did not require surgical intervention. Discussion/Conlusion: Our study shows that guidewire exchange of a tunneled HD catheter by creating a new exit site and a new subcutaneous tunnel by using the same venous access is a newer method in chronic HD patients. This procedure should not be used in patients with coagulation issues. Additional studies are needed to compare the different methods of HD catheter exchange.

Switch from Hemodialysis to Peritoneal Dialysis: Does the Time Spent on Hemodialysis Impact Outcomes in Peritoneal Dialysis?

INTRODUCTION: Switch from hemodialysis (HD) to peritoneal dialysis (PD) is unfrequent, but incentive strategies to perform PD can lead to an increase of these transitions. However, data on transitioning from HD to PD are scarce. We hypothesized that time spent on HD before transfer to PD would impact PD outcomes. METHODS: This registry-based, nationwide study analyzed patients transferred from HD to PD. Patients who began HD between January 2008 and December 2016 were included. Cox and Fine and Gray regression models were used to explore the relationship between time spent on HD before PD and outcomes in PD: PD cessation for death or retransfer to HD (composite endpoint); for death; and for retransfer to HD. RESULTS: Over the study period, 1,985 of the 77,587 HD starters (3%) were transferred to PD. The median time spent on HD before transfer to PD was 1.94 months (interquartile range [IQR] 1.02-4.01). The median survival time on PD after this transition was 20 months (IQR 18-21). Time spent on HD before PD was associated with increased risk of death or retransfer to HD (cause-specific hazard ratio [cs-HR] 1.01, 95% confidence interval [CI]: 1-1.02 for a 1-month increase) and death (cs-HR 1.02, 95% CI: 1.01-1.03) but not with retransfer to HD censored on death (cs-HR 1.00, 95% CI: 0.99-1.01). The results were similar when considering competing events. DISCUSSION/CONCLUSION: Switch from HD to PD is rare in France. Time spent on HD before transfer is associated with patient survival but not with retransfer to HD.

Are sex differences in the outcome of peritoneal dialysis explained by nurse assistance? A cohort study with data from the Registre de Dialyse Péritonéale de Langue Française.

BACKGROUND: We aimed to evaluate sex differences in peritoneal dialysis (PD) outcomes and to explore direct and indirect effects of nurse-assisted PD on outcomes. METHODS: This was a retrospective study using data from the Registre de Dialyse Péritonéale de Langue Française of incident PD patients between 2005 and 2016. Cox proportional hazards modelling was used to analyse transfer to haemodialysis (HD), death, PD failure, peritonitis and renal transplantation. Mediation analyses with a counterfactual approach were carried out to evaluate natural direct and indirect effects of sex on transfer to HD and peritonitis, with nurse-assisted PD as a mediator a priori. RESULTS: Of the 14 659 patients included, there were 5970 females (41%) and 8689 males (59%). Women were more frequently treated by nurse-assisted PD than men [2926/5970 (49.1%) versus 3357/8689 (38.7%)]. In the multivariable analysis, women had a lower risk of transfer to HD [cause-specific hazard ratio {cs-HR} 0.82 {95% confidence interval (CI) 0.77-0.88}], death [cs-HR 0.90 (95% CI 0.85-0.95)], peritonitis [cs-HR 0.82 (95% CI 0.78-0.87)], PD failure [cs-HR 0.86 (95% CI 0.83-0.90)] and a lower chance of undergoing transplant [cs-HR 0.83 (95% CI 0.77-0.90)] than men. There was a direct effect of sex on the risk of transfer to HD [cs-HR 0.82 (95% CI 0.82-0.83)], with an indirect effect of nurse-assisted PD [cs-HR 0.97 (95% CI 0.96-0.99)]. Nurse-assisted PD had no indirect effect on the risk of peritonitis. CONCLUSIONS: Our results suggest that compared with men, women have a lower risk of both transfer to HD and peritonitis. Mediation analysis showed that nurse assistance was a potential mediator in the causal pathway between sex and transfer to HD.

Dialysis-network variability in home dialysis use not explained by patient characteristics: a national registry-based cohort study in France.

BACKGROUND: Although associated with better quality of life and potential economic advantages, home dialysis use varies greatly internationally and appears to be underused in many countries. This study aimed to estimate the dialysis-network variability in home dialysis use and identify factors associated with (i) the uptake in home dialysis, (ii) the proportion of time spent on home dialysis and (iii) home dialysis survival (patient and technique). METHODS: All adults ≥18 years old who had dialysis treatment during 2017-2019 in mainland France were included. Mixed-effects regression models were built to explore factors including patient or residence characteristics and dialysis network associated with variation in home dialysis use. RESULTS: During 2017-2019, 7728/78 757 (9.8%) patients underwent dialysis at least once at home for a total of 120 594/1 508 000 (8%) months. The heterogeneity at the dialysis-network level and to a lesser extent the regional level regarding home dialysis uptake or total time spent was marginally explained by patient characteristics or residence and dialysis-network factors. Between-network heterogeneity was less for patient and technique survival. These results were similar when the analysis was restricted to home peritoneal dialysis or home hemodialysis. CONCLUSIONS: Variability between networks in the use of home dialysis was not fully explained by non-modifiable patient and residence characteristics. Our results suggest that to increase home dialysis use in France, one should focus on home dialysis uptake rather than survival. Financial incentives and a quality improvement programme should be implemented at the dialysis-network level to increase home dialysis use.

Effect of age and care organization on sources of variation in kidney transplant waiting list registration.

Despite national guidelines, medical practices and kidney transplant waiting list registration policies may differ from one dialysis/transplant unit to another. Benefit risk assessment variations, especially for elderly patients, have also been described. The aim of this study was to identify sources of variation in early kidney transplant waiting list registration in France. Among 16 842 incident patients during the period 2016-2017, 4386 were registered on the kidney transplant waiting list at the start of, or during the first year after starting, dialysis (26%). We developed various log-linear mixed effect regression models on three levels: patients, dialysis networks, and transplant centers. Variability was expressed as variance from the random intercepts (± standard error). Although patient characteristics have an important impact on the likelihood of registration, the overall magnitude of variability in registration was low and shared by dialysis networks and transplant centers. Between-transplant center variability (0.23 ± 0.08) was 1.8 higher than between-dialysis network variability (0.13 ± 0.004). Older age was associated with a lower probability of registration and greater variability between networks (0.04, 0.20, & 0.93 in the 18-64, 65-74, and 75-84 age groups). Targeted interventions should focus on elderly patients and/or certain regions with greater variability in waiting list access.

Trends in Peritoneal Dialysis Technique Survival, Death, and Transfer to Hemodialysis: A Decade of Data from the RDPLF.

INTRODUCTION: There is limited information on the trends of peritoneal dialysis (PD) technique survival over time. This study aimed to estimate the effect of calendar time on technique survival, transfer to hemodialysis (HD) (and the individual causes of transfer), and patient survival. METHODS: This retrospective, multicenter study, based on data from the French Language Peritoneal Dialysis Registry, analyzed 14,673 patients who initiated PD in France between January 1, 2005, and December 31, 2016. Adjusted Cox regressions with robust variance were used to examine the probability of a composite end point of either death or transfer to HD, death, and transfer to HD, accounting for the nonlinear impact of PD start time. RESULTS: There were 10,201 (69.5%) cases of PD cessation over the study period: 5,495 (37.4%) deaths and 4,706 (32.1%) transfers to HD. The rate of PD cessation due to death or transfer to HD decreased over time (PR 0.96, 95% CI: 0.95-0.97). Compared to 2009-2010, starting PD between 2005 and 2008 or 2011 and 2016 was strongly associated with a lower rate of transfer to HD (PR 0.88, 95% CI: 0.81-0.96, and PR 0.91, 95% CI: 0.84-0.99, respectively), mostly due to a decline in the rate of infection-related transfers to HD (PR 0.96, 95% CI: 0.94-0.98). CONCLUSIONS: Rates of the composite end point of either death or transfer to HD, death, and transfer to HD have decreased in recent decades. The decline in transfers to HD rates, observed since 2011, is mainly the result of a significant decline in infection-related transfers.

Assisted peritoneal dialysis and transfer to haemodialysis: a cause-specific analysis with data from the RDPLF.

BACKGROUND: Technique failure, defined as death or transfer to haemodialysis (HD), is a major concern in peritoneal dialysis (PD). Nurse-assisted PD is globally associated with a lower risk of transfer to HD. We aimed to evaluate the association between assisted PD and the risk of the different causes of transfer to HD. METHODS: This was a retrospective study using data from the French Language PD Registry of patients on incident PD from 2006 to 2015. The association between the use of assisted PD and the causes of transfer to HD was evaluated using survival analysis with competing events in unmatched and propensity score-matched cohorts. RESULTS: The study included 11 093 incident PD patients treated in 123 French PD units. There were 4273 deaths, 3330 transfers to HD and 2210 renal transplantations. The causes of transfer to HD were inadequate dialysis (1283), infection (524), catheter-related problems (334), social issues (250), other causes linked to PD (422), other causes not linked to PD (481) and encapsulating peritoneal sclerosis (6). Nurse-assisted PD patients were older and more comorbid. Assistance by nurse was associated with a higher risk of death [cause-specific hazard ratio (cs-HR) 2.49, 95% confidence interval (CI) 2.26-2.74], but with a lower risk of transfer to HD [subdistributionHR (sd-HR) 0.68, 95% CI 0.62-0.76], especially due to inadequate dialysis (cs-HR 0.83, 95% CI 0.75-0). CONCLUSIONS: The lower risk of transfer to HD associated with nurse assistance should encourage decision makers to launch reimbursement programmes in countries where it is not available.

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients.

The aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed.

Is self-care dialysis associated with social deprivation in a universal health care system? A cohort study with data from the Renal Epidemiology and Information Network Registry.

BACKGROUND: Socioeconomic status is associated with dialysis modality in developed countries. The main objective of this study was to investigate whether social deprivation, estimated by the European Deprivation Index (EDI), was associated with self-care dialysis in France. METHODS: The EDI was calculated for patients who started dialysis in 2017. The event of interest was self-care dialysis 3 months after dialysis initiation [self-care peritoneal dialysis (PD) or satellite haemodialysis (HD)]. A logistic model was used for the statistical analysis, and a counterfactual approach was used for the causal mediation analysis. RESULTS: Among the 9588 patients included, 2894 (30%) were in the most deprived quintile of the EDI. A total of 1402 patients were treated with self-care dialysis. In the multivariable analysis with the EDI in quintiles, there was no association between social deprivation and self-care dialysis. Compared with the other EDI quintiles, patients from Quintile 5 (most deprived quintile) were less likely to be on self-care dialysis (odds ratio 0.81, 95% confidence interval 0.71-0.93). Age, sex, emergency start, cardiovascular disease, chronic respiratory disease, cancer, severe disability, serum albumin and registration on the waiting list were associated with self-care dialysis. The EDI was not associated with self-care dialysis in either the HD or in the PD subgroups. CONCLUSIONS: In France, social deprivation estimated by the EDI is associated with self-care dialysis in end-stage renal disease patients undergoing replacement therapy.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy. METHODS: We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters. RESULTS: More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group. CONCLUSIONS: Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

Effects of educational practices on the peritonitis risk in peritoneal dialysis: a retrospective cohort study with data from the French peritoneal Dialysis registry (RDPLF).

BACKGROUND: Peritoneal dialysis (PD) is a home-based therapy performed by patients or their relatives in numerous cases, and the role of patients' educational practices in the risk of peritonitis is not well assessed. Our aim was to evaluate the effect of PD learning methods on the risk of peritonitis. METHODS: This was a retrospective multicentric study based on data from a French registry. All incident adults assisted by family or autonomous for PD exchanges in France between 2012 and 2015 were included. The event of interest was the occurrence of peritonitis. Cox and hurdle regression models were used for statistical analysis to asses for the survival free of peritonitis, and the risk of first and subsequent peritonitis. RESULTS: 1035 patients were included. 967 (93%) received education from a specialized nurse. Written support was used for the PD learning in 907 (87%) patients, audio support in 221 (21%) patients, and an evaluation grid was used to assess the comprehension in 625 (60%) patients. In the "zero" part of the hurdle model, the use of a written support and starting PD learning with hands-on training alone were associated with a lower survival free of peritonitis (respectively HR 1.59, 95%CI 1.01-2.5 and HR 1.94, 95%CI 1.08-3.49), whereas in the "count" part, the use of an audio support and starting of PD learning with hands-on training in combination with theory were associated with a lower risk of presenting further episodes of peritonitis after a first episode (respectively HR 0.55, 95%CI 0.31-0.98 and HR 0.57, 95%CI 0.33-0.96). CONCLUSIONS: The various PD education modalities were associated with differences in the risk of peritonitis. Prospective randomized trials are necessary to confirm causal effect. Caregivers should assess the patient's preferred learning style and their literacy level and adjust the PD learning method to each individual.

Assessment for Assisted Peritoneal Dialysis by Peritoneal Dialysis Nurses: Results of a Cohort Study.

BACKGROUND: Selection of patients for assisted peritoneal dialysis (PD) is based on the nurse's assessment of the patient. There is no data available about the nurse's assessment of the PD patient at the initiation of PD to estimate the need for assisted PD at the national level. This study was carried out to evaluate the association between the nurse's subjective assessment of the patient's inability to be treated by self-care PD, the nurse evaluation of the patient disabilities and the utilization of nurse or family assisted PD. METHODS: This was a retrospective study of patients starting PD between July 1, 2010 and 2015 and registered in the nurse section of the French Language PD Registry (RDPLF). Poisson regression and a linear regression model with a robust variance estimator were used for the statistical analysis to determine relative risks (RRs) and risk differences (RDs). RESULTS: Of 4,101 PD patients, 403 were treated by family assisted PD, and 1,695 were treated by nurse-assisted PD. In the multivariate analysis, the nurse's subjective assessment of the patient's inability to be treated by self-care PD was associated with nurse-assisted PD (5.40 [4.58-6.35], 67% [64-70%]) and family assisted PD (11.11 [8.49-14.56], RD 62% [57-67%]). Nurse-assisted PD and family assisted PD were associated with functional impairment (RR 1.25 [95% CI 1.16-1.36], RD 14% [95% CI 10-19%] and RR 2.02 [95% CI 1.69-2.41], RD 27% [95% CI 20-34%] respectively), cognitive dysfunction (RR 1.23 [95% CI 1.15-1.32], RD 15% [95% CI 11-18%] and RR 1.73 [95% CI 1.39-2.16], RD 12% [95% CI 7-18%] respectively) and deafness (RR 1.10 [95% CI 1.04-1.16], RD 8% [95% CI 5-11%] and RR 1.46 [95% CI 1.22-1.74], RD 10% [95% CI 6-14%] respectively). CONCLUSION: Our results showed that the nurse's subjective assessment of the patient's inability to be treated by self-care PD and the patient's disabilities were strongly associated with the utilization of nurse- and family assisted PD.

Impact of Assisted Peritoneal Dialysis Modality on Outcomes: A Cohort Study of the French Language Peritoneal Dialysis Registry.

BACKGROUND: Patients on peritoneal dialysis (PD) can be assisted by a nurse or a family member and treated either by automated PD (APD) or continuous ambulatory PD (CAPD). The aim of this study was to evaluate the effect of PD modality and type of assistance on the risk of transfer to haemodialysis (HD) and on the peritonitis risk in assisted PD patients. METHOD: This was a retrospective study based on data from the French Language PD Registry. All adults starting assisted PD in France between 2006 and 2015 were included. Events of interest were transfer to HD, peritonitis and death. Cox regression models were used for statistical analysis. RESULTS: Among the 12,144 incident patients who started PD in France during the study period, 6,167 were assisted. There were 5,060 nurse-assisted and 1,095 family-assisted PD patients. Overall, 5,171 were treated by CAPD and 996 by APD. In multivariate analysis, CAPD, compared to APD, was not associated with the risk of transfer to HD (cause specific hazard ratios [cs-HR] 0.96 [95% CI 0.84-1.09]). Patients on nurse-assisted PD had a lower risk of transfer to HD than family assisted PD patients (cs-HR 0.85 [95% CI 0.75-0.97]). Neither PD modality nor type of assistance were associated with peritonitis risk. CONCLUSIONS: In assisted PD, technique survival was not associated with PD modality. Nurse-assisted patients had a lower risk of transfer to HD than family assisted patients. Peritonitis risk was not influenced either by PD modality, or by type of assistance. Both APD and CAPD should be offered to assisted-PD patients.

Factors associated with nurse assistance among peritoneal dialysis patients: a cohort study from the French Language Peritoneal Dialysis Registry.

Background: No information is available regarding nurse-assisted peritoneal dialysis (PD) in non-elderly subjects. This study was carried out to estimate the rate of nurse-assisted PD among non-elderly patients and to assess which individual and centre factors were associated with nurse-assisted PD. The other objective was to estimate the magnitude of the centre effect on the utilization of nurse-assisted PD using hierarchical modelling. Methods: This was a retrospective study based on data from the French Language Peritoneal Dialysis Registry. Patients incident on PD > 18 and < 65 years of age were included. Results: There were 2269 incidents of PD initiation between January 2008 and December 2012 in 127 PD centres with 114 (5%) on family-assisted PD and 272 (12%) on nurse-assisted PD. At the individual level, compared with autonomous patients, nurse assistance was associated with age {odds ratio [OR] 1.79 [95% confidence interval (CI) 1.51-2.13]}, gender [OR 0.47 (95% CI 0.35-0.64)], comorbidities and underlying nephropathy. There was significant heterogeneity between centres in the nurse assistance utilization (variance of random effect 0.12). At the centre level, the type of centre, centre experience, centre organization and private nurse density were not associated with nurse-assisted PD. Conclusions: The rate of nurse-assisted PD among non-elderly patients was 12%. There was a significant centre effect in the utilization of nurse assistance that was not explained by the centres' characteristics. Nurse-assisted PD utilization in non-elderly patients is associated with patient characteristics and also with centre practices.

Survival advantage of planned haemodialysis over peritoneal dialysis: a cohort study.

Background: Previous studies comparing the outcomes in haemodialysis (HD) with those in peritoneal dialysis (PD) have yielded conflicting results. Methods: The aim of the study was to compare the survival of planned HD versus PD patients in a cohort of adult incident patients who started renal replacement therapy (RRT) between 2006 and 2008 in the nationwide REIN registry (Réseau Epidémiologie et Information en Néphrologie). Patients who started RRT in emergency or stopped RRT within 2 months were excluded. Adjusted Cox models, propensity score matching and marginal structural models (MSMs) were used to compensate for the lack of randomization and provide causal inference from longitudinal data with time-dependent treatments and confounders including transplant censorship, modality change over time and time-varying covariates. Results: Among a total of 13 767 dialysis patients, 13% were on PD at initiation of RRT and 87% were on HD. The median survival times were 53.5 months or 4.45 years and 38.6 months or 3.21 years for patients starting on HD and PD, respectively. Regardless of the model used, there was a consistent advantage in terms of survival for HD patients: hazard ratio (HR) 0.76 [95% confidence interval (95% CI) 0.69-0.84] with the Cox model using propensity score; HR 0.67 (95% CI 0.62-0.73) in the Cox model with censorship for each treatment change; and HR 0.82 (95% CI 0.69-0.97) with MSMs. However, MSMs tended to reduce the survival gap between PD and HD patients. Conclusion: This large cohort study using various statistical methods to minimize the bias appears to demonstrate a better survival in planned HD than in PD.

Does the Blood Pump Flow Rate have an Impact on the Dialysis Dose During Low Dialysate Flow Rate Hemodialysis?

We conducted a prospective study to assess the impact of the blood pump flow rate (BFR) on the dialysis dose with a low dialysate flow rate. Seventeen patients were observed for 3 short hemodialysis sessions in which only the BFR was altered (300,350 and 450 mL/min). Kt/V urea increased from 0.54 ± 0.10 to 0.58 ± 0.08 and 0.61 ± 0.09 for BFR of 300, 400 and 450 mL/min. For the same BFR variations, the reduction ratio (RR) of ß2microglobulin increased from 0.40 ± 0.07 to 0.45 ± 0.06 and 0.48 ± 0.06 and the RR phosphorus increased from 0.46 ± 0.1 to 0.48 ± 0.08 and 0.49 ± 0.07. In bivariate analysis accounting for repeated observations, an increasing BFR resulted in an increase in spKt/V (0.048 per 100 mL/min increment in BPR [p < 0.05, 95% CI (0.03-0.06)]) and an increase in the RR ß2m (5% per 100 mL/min increment in BPR [p < 0.05, 95% CI (0.03-0.07)]). An increasing BFR with low dialysate improves the removal of urea and ß2m but with a potentially limited clinical impact.

Survival of patients with cancer starting chronic dialysis: Data from kidney and cancer registries in lower Normandy.

AIM: Cancer and chronic kidney disease are known to be associated. The way in which a history of cancer can influence outcome in dialysis is not well described. This work aimed to evaluate survival of cancer patients starting chronic dialysis after their diagnosis of cancer. METHODS: We merged data from cancer registries and a dialysis registry, and explored patients' charts. RESULTS: Between January 2001 and December 2008, 74 patients with incident cancer in the two-counties-study-area (Calvados and Manche) started chronic dialysis after their diagnosis of cancer. Survival of these incident dialysis patients with a previous diagnosis of cancer was respectively 80.9% (confidence interval 69.9; 88.2) and 68.3% (confidence interval 56.3%; 77.7%) at 1 and 2 years. Only 29 of the 74 patients (39.2%) were still alive at the end of the observation period; median participation time was 2.8 years (1st and 3rd quartiles: 1.3-4.4). Survival of patients with cancer was not different to that of non-cancer dialysis patients matched for age and sex, except in patients with haematological malignancies who had a poorer outcome. In a multivariate stratified Cox model, the history of cancer before dialysis start was not associated with death, after adjustment on diabetes. CONCLUSION: In our study, survival in dialysis was not different among patients with a history of cancer compared to matched patients without malignancy. We can hypothesize that only some selected patients with cancer have access to dialysis. Studies in ESRD patients with cancer should be performed to evaluate access to dialysis in that population.

Chronic respiratory disease: an unrecognized risk factor in dialysis.

BACKGROUND: Few studies have analysed the impact of chronic respiratory disease (CRD) on outcomes in dialysis. We therefore sought to describe patients with CRD and end-stage renal disease and their outcomes after dialysis start, compared with patients without CRD, focusing especially on causes of death, access to renal transplantation and causes of hospital admissions. METHODS: The study included 52 797 adults aged 18 years and older who began dialysis from 2008 to 2013 and are recorded in the French national REIN registry. Survival, specific mortality and access to the waiting list and to renal transplantation were analysed, with adjustment for various comorbidities and consideration of competitive risks. The numbers of hospitalizations and hospital days, together with their causes, were analysed through an indirect link between the REIN database and the national French hospital discharge database. RESULTS: The frequency of CRD at dialysis start was 12% and was associated with various other comorbidities, including obesity and tobacco use. After adjustment for those comorbidities, CRD remained associated with a higher risk of death [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.16-1.25]. Patients with CRD were 30% less likely to undergo transplantation (HR 0.67, 95% CI 0.6-0.7) than patients without CRD. Their risk of dying from a respiratory disease was 8.8 times higher; their risk of dying from infection was also higher. Patients with CRD had a higher rate of admissions and more hospital days, for all causes and for every cause, except cancer. CONCLUSIONS: CRD was associated with higher risks of death and hospital admissions and with lower likelihoods of being wait-listed for and undergoing renal transplantation. Increasing clinical awareness by patients and doctors and encouragement of spirometry use should promote more accurate clinical diagnosis and better preventive care for CRD.